An insight into the use of telemedicine technology for cancer patients during the Covid-19 pandemic: a scoping review

Background The use of telemedicine technology has significantly increased in recent years, particularly during the Covid-19 pandemic. This study aimed to investigate the use of telemedicine technology for cancer patients during the Covid-19 pandemic. Methods This was a scoping review conducted in 2023. Various databases including PubMed, Web of Science, Scopus, Cochrane Library, Ovid, IEEE Xplore, ProQuest, Embase, and Google Scholar search engine were searched. All quantitative, qualitative, and mixed-method studies published in English between 2020 and 2022 were included. Finally, the needed data were extracted, and the results were synthesized and reported narratively. Results A total of 29 articles were included in this review. The results showed that teleconsultation, televisit, and telerehabilitation were common telemedicine services, and video conferencing and telephone were common technologies used in these studies. In most cases, patients and healthcare providers preferred these services compared to the face-to-face consultations due to their convenience and advantages. Furthermore, the findings revealed that in terms of clinical outcomes, telemedicine could effectively reduce anxiety, pain, sleep disorders, and hospital admission rates. Conclusion The findings provided valuable insights into the various telemedicine technologies, services, users’ perspectives, and clinical outcomes in cancer patients during the Covid-19 pandemic. Overall, the positive outcomes and users’ satisfaction showed that the use of telemedicine technology can be expanded, particularly in cancer care. Future research needs to investigate both clinical and non-clinical effectiveness of using various telemedicine services and technologies for improving cancer care delivery, which can help to develop more successful strategies for implementing this technology.


Background
Cancer is a widespread public health concern, with more than 19 million new cancer cases and about 10 million cancer-related deaths reported worldwide in 2020 [1,2].
The International Agency for Research on Cancer (IARC) reported that globally, one out of five people is susceptible to develop cancer during their lifetime, and one out of every eight men and one out of every 11 women may die from cancer.It seems that an increase in the global population, diseases, and economic factors are the main risk factors for increasing the prevalence of cancer [3].
Recent studies have shown that cancer patients face an increased possibility of being diagnosed with Covid-19 and they experience more severe clinical manifestations [4].Moreover, the mortality of cancer patients due to Covid-19 is higher compared to the people without cancer [5].Cancer patients are more affected by the side effects of Covid-19, and the lack of adequate and timely care for these patients may lead to an increase in their mortality rate [4].
There are a number of risk factors that cause cancer patients being affected by Corona virus transmission.These risk factors include the progression of the disease, the suppressive nature of the immune system, frequent visits to hospitals for active chemotherapy, radiotherapy, immunotherapy, targeted therapy and immunosuppressant for bone marrow transplantation [6,7].As a result, telemedicine tools have been recommended to reduce disease transmission rates while continuing medical care provision remotely, particularly during the pandemic [8,9].
Although telemedicine technology is not a novel method for providing cancer patients with a variety of healthcare services, such as diagnosis, consultation, treatment, and home care [10], the use of this technology has increased during the Covid-19 pandemic, mainly due to the high workload on the healthcare system and the provision of global strategies such as social distancing and quarantine requirements.These reasons encouraged cancer patients to use telemedicine technologies instead of receiving an in-person visit in medical centers [11,12].The use of telemedicine has a number of advantages.For example, it can help to reduce the waiting times compared to the traditional in-person visits at healthcare centers [13].However, despite the advantages and positive users' attitudes, there are still concerns over the lack of face-to-face communication and the inability to conduct physical examinations [14].
So far, several review studies have been conducted; however, a few of them discussed the use of telemedicine technology by cancer patients during the Covid-19 pandemic [15][16][17].The review studies in this area were also scarce and their objectives were different [15,17,18].
Therefore, in the current study, we aimed to conduct a scoping review to systematically investigate and consolidate the evidence related to the application of telemedicine technology for cancer patients during the Covid-19 pandemic.By adopting a scoping review methodology, we could provide a comprehensive understanding of different types of technology, services, users' perspectives, and clinical outcomes of using telemedicine technology within the context of cancer care during the pandemic.The results can be useful for future research, further technology development, and response to the unique needs of cancer patients especially during the pandemic.

Methods
This scoping review was conducted in 2023 and different types of research, in which telemedicine intervention was used for cancer patients during the Covid-19 pandemic and its outcome was evaluated, were reviewed.Unlike systematic reviews, which typically focus on a narrow research question and employ a rigorous method to assess the risk of bias and quality, scoping reviews provide a broad overview of the available literature without a formal assessment of these factors [19].To achieve this goal, Arksey and O'Malley's framework [19] was used.Before conducting this research, ethics approval (IR.IUMS.REC.1401.392)was obtained from the National Ethics Committee of Biomedical Research.

Stage 1: identifying the research question
Before developing a search strategy for review studies, the research question should be explained clearly.The initial literature review suggested that the literature about the use of telemedicine technology for cancer patients during the Covid-19 pandemic was scarce; therefore, we generated research questions as follows: How was telemedicine technology used for cancer patients during the Covid-19 pandemic?What was the outcome of telemedicine technology used for cancer patients compared to in-person visits?

Stage 2: identifying relevant studies
To identify relevant studies, eight databases including PubMed, Web of Science, Scopus, Cochrane Library, Ovid, IEEE Xplorer, ProQuest, and Embase as well as the Google Scholar search engine were searched.The search timeframe was between 1st January 2020 and 31th December 2022 to access all relevant studies published during the pandemic.The search strategy consisted of three main terms: "Covid-19", "Telemedicine" and "Cancer, " along with their corresponding synonyms and MeSH terms.All of them were combined using AND OR logical operators to create search strategies for different databases (Table 1).The reference list of the selected studies and their citations were also searched to ensure that all relevant studies were included.

Stage 3: study selection
The current study utilized specific criteria for including and excluding articles during the selection process.The inclusion criteria consisted of original articles published in English in which quantitative, qualitative, or mixed methods approaches were used to evaluate telemedicine interventions for cancer patients during the Covid-19 pandemic, and their results were compared with the inperson visits.
The exclusion criteria encompassed review articles, letters to the editor, protocols, and studies that did not involve the evaluation of telemedicine technology by cancer patients or their care providers.Furthermore, studies that were not published in the English language, those that focused on cancer survivors instead of individuals currently undergoing treatment, those that did not report clinical outcomes or did not gather users' perspectives (patients or care providers), abstract-only documents,

Stage 4: charting the data
To perform a complete search on the subject, all related keywords and MeSH terms were identified and combined.The retrieved studies were organized using EndNote software, and after removing duplicates, the remaining articles were screened in terms of the title and abstract relevancy to the aim of the study.The full text of eligible studies was then retrieved and reviewed.Both authors contributed to screen the articles independently and any disagreements between them were resolved via discussion.
The required data were extracted using a data extraction form and included the author(s) name, country of the study, year of publication, study objective, type of telemedicine technology, type of cancer, type of services (such as diagnosis, treatment, consultation, screening or home care), users' (patients' and healthcare providers') perspectives regarding the use of telemedicine technology for cancer patients during the Covid-19 pandemic, and clinical outcomes.

Stage 5: collating, summarizing, and reporting the results
The extracted data were tabulated, summarized, and reported narratively.Results were reported by categorizing studies according to the type of services, type of technology, patients' and providers' opinions, and clinical outcomes.

Results
Initially, 3501 articles were retrieved and after completing the screening process based on the PRISMA-ScR statement and applying the inclusion and exclusion criteria, 29 studies  were identified for the final review.Figure 1 shows the process of selecting articles.
Similarly, telephone-based telemedicine services helped with receiving advice about the clinical symptoms of cancer patients [23,29,36,42,47], scheduling the next appointments [27,28,39], and receiving regular consultation services [22, 23, 26-29, 33, 36-45, 47].In addition, for cancer patients who were in the initial stages of the disease, telephone consultation was an effective way to receive continuous care and support [45].In Chen et al. 's study, the results showed that the messenger applications facilitated message exchange for the rehabilitation of cancer patients during the Covid-19 pandemic [21].
Telerehabilitation was another telemedicine service which was used to provide physiotherapy [21,38] and occupational therapy [37] for cancer patients during the Covid-19 pandemic Telemonitoring was used to continuously track vital signs and provided feedback regarding the progress of patient rehabilitation, which could be useful in motivating and improving the effectiveness of telerehabilitation in the era of Covid-19 [21].

Patients' and healthcare providers' perspectives
According to the results, in some studies, patients were highly satisfied with telemedicine services [20,30,39,44,45,48].Patient satisfaction was specifically related to the audio/video quality [30,39], ease of communication [30,38], technology ease of use [30,38,39], comfort, appropriate length of visit, and overall experience of using telemedicine technology compared to the in-person visits [44].In some studies, physicians were also highly satisfied with the use of telemedicine technology in the field of cancer care [20,30,45].For example, Aghdo et al. showed that physicians were satisfied with the teamwork, increased communication, and quality of care which were resulted from using telemedicine technology [30].
Patients were concerned about the lack of access to communication tools and appropriate equipment (such as the Internet and personal computers) [38], low technical skills and e-literacy [24,33,34,37,38,41], medical responsibility [20], and care quality through telemedicine [20,37,39].Similarly, healthcare providers were concerned with the compatibility of technology with their common workflows [33,35,41], limited access to patient information and medical records [20,33,41], and reimbursement difficulties [20,33,41] as challenges hindering them from using telemedicine effectively.The results of some studies also showed that telephone consultations may cause several challenges, such as delay in diagnosis [27] and limiting physician-patient interactions [27].In addition, it can be challenging for patients with language or hearing impairments to use this technology effectively [42].

Clinical outcomes
In addition to the non-clinical benefits of telemedicine technology, several studies have demonstrated that patients who received care through this technology experienced positive clinical outcomes, such as reduction in anxiety [24,27,29,38], pain [21,23], sleep disorders [21,23], fatigue [23], and uncontrolled appetite [21,23] compared to those who had in-person visits.For instance, Chen et al. found that telerehabilitation was associated with reduced difficulty swallowing saliva, asphyxia, and cough among patients with head and neck cancers [21].Other positive clinical outcomes of telemedicine over inperson consultations included reducing hospitalization and emergency care visits [33,36,46], reducing mortality rates [29], and improving treatment outcomes [42] for patients undergoing systemic anti-cancer treatments.Additionally, telemedicine can lead to faster biopsy consultation and diagnosis processes compared to the inperson visits [47].

Synthesis
Overall, the synthesis of the results showed that telemedicine was widely used for cancer patents during the Covid-19 pandemic.Like other chronic diseases, teleconsultation and televisit were the most common methods for delivering healthcare services.Although patients and healthcare providers were generally satisfied with this technology, a number of technical and non-technical challenges are still remaining which need further attention.

Discussion
During the Covid-19 pandemic, telemedicine was identified as a valuable intervention to facilitate the provision of care services for cancer patients [17].This study aimed to investigate the use of telemedicine technology for cancer patients during the Covid-19 pandemic.The results revealed that video conferencing, telephone consultation, messaging applications, such as WeChat, and telemonitoring were commonly used technologies.Popular platforms included Zoom, Jeff Connect, Microsoft Teams, WeChat, and My Chart.Teleconsultation, televisit, and telerehabilitation were among the most frequently offered services.Overall, both healthcare providers and patients were highly satisfied with the telemedicine technology.The benefits of telemedicine included eliminating unnecessary travel time and costs, facilitating access to medical services, and reducing the risk of exposure to Covid-19.However, potential challenges such as limited access to, or proficiency with the communication tools or equipment, lack of technical skills, low level of e-literacy, and concerns over quality assurance are still remaining.Additionally, the findings suggested that using telemedicine helped to reduce anxiety levels, pain, sleep disorders, fatigue, and uncontrolled appetite while decreasing emergency care needs in many cases.
Several studies have demonstrated that video conferencing is an effective method for delivering virtual faceto-face consultations to the cancer patients during the Covid-19 pandemic [17,49].This technology has been used to facilitate screening, counseling, rehabilitation, mental health support [16], while improving clinical outcomes [50].Additionally, video conferencing can help to reduce travel time and costs.However, some potential challenges, such as poor Internet connectivity, concerns over privacy and security, and limitations in conducting physical examinations or remote diagnostic tests still need further attentions [51].Fortunately, the use of popular platforms such as WhatsApp, Zoom, and Skype has helped with conducting video conferencing sessions between healthcare providers and patients [52].
Several studies have indicated that telephone counseling can be an effective tool in providing palliative care for cancer patients [53] and can assist with providing mental health support to manage their anxiety and stress associated with the treatments [54].Furthermore, with the increasing use of smartphones, messaging applications like WhatsApp, Viber, and WeChat [55] have been used to provide palliative support and rehabilitation services to cancer patients, leading to better management of clinical symptoms [56].In addition, the use of these platforms has increased awareness among cancer patients regarding the treatment options during Covid-19 [56], and improved their functional capacity, psychological well-being, and overall quality of life [57].
Our study findings are consistent with other studies in which teleconsultation has been identified as one of the most commonly used telemedicine services for cancer patients during the Covid-19 pandemic [17].Teleconsultation has proven to be an efficient and effective tool for receiving medical care, and timely palliative and emotional counseling outside of the hospital settings [58].Similarly, televisit services have been used to maintain ongoing care delivery and support cancer patients during the pandemic.These virtual visits offered a valuable alternative for urgent medical care needs when in-person consultations were not feasible due to the social restrictions [59,60] In addition, telerehabilitation services have demonstrated benefits in improving muscle strength, functional ability, pain relief, and reducing sleep disorders among cancer patients undergoing surgery or chemotherapy during the pandemic [61,62].Telemonitoring was also found to be effective in tracking the vital signs of cancer patients and providing feedback on rehabilitation progress during the pandemic [21,63].This finding is supported by Steimer et al. 's study which showed that telemonitoring improved clinical outcomes and vital signs, and reduced hospitalization rates compared to the in-person visits among cancer patients [64].
Our research findings demonstrated that telemedicine services have also increased patients' and healthcare providers' satisfaction mainly due to maintaining quality of care and positive clinical outcomes compared to the inperson visits [60,65,66].This positive feedback can help to accelerate development and implementation of telemedicine technology for cancer patients [67].Although the effectiveness of telemedicine may vary depending on various factors, such as patient characteristics, type of cancer and its stage [14,68], patients still use this type of services for various reasons, including reduced waiting times/costs [69], ease of accessibility/use, reduction in physician visits, improved treatment follow-up, and increased comfort levels [70].Apart from their positive feedback, their concerns need to be addressed, too.It is crucially important to address infrastructure deficiencies and resolve technical issues, and reimbursement challenges for encouraging continuous use of telemedicine services [71,72].

Implications for practice
This research provided an insight into the use telemedicine for cancer care during the Covid-19 pandemic.According to the findings, it is essential to customize telemedicine platforms to address users' concerns regarding the quality of audio and video materials, as well as the ease of communication.Adapting services to meet the specific needs of patients at various stages of cancer care improves their overall satisfaction.Moreover, it is crucial to address technical obstacles, such as the Internet connectivity issues, in order to achieve a smooth telemedicine experience.Promoting patient engagement through effective communications, improving patient-physician interactions, and paying more attention to the positive clinical outcomes, such as decreased anxiety and pain, are necessary to encourage patients and their healthcare providers to use telemedicine services more effectively, despite ongoing challenges posed by the pandemic.
The experiences obtained during the Covid-19 pandemic can also contribute to plan for the future and better use of the telemedicine technology.In fact, by leveraging the recent literature, evidence-based findings, and best practices in telemedicine implementation, this technology can be adopted more effectively and broadly in cancer care in the post-Covid era, as its weaknesses have been previously identified and now, they need to be addressed properly.Furthermore, as patients and healthcare providers are relatively ready to accept the technology, team working and establishing interdisciplinary collaborations among oncologists, information technology experts, and policymakers can help to develop new implementation strategies tailored to the specific needs of cancer patients to promote the adoption of telemedicine technology.

Strengths and limitations of the study
This scoping review enhanced our understanding about using telemedicine for cancer care during the Covid-19 pandemic through a thorough examination of different technologies, their applications, and outcomes.Presenting users' perspectives and experiences with telemedicine technology, challenges and clinical outcomes compared with the results of the in-person visits were other strengths of this study which can make a substantial contribution to the ongoing endeavors aimed at enhancing and promoting the consistent utilization of telemedicine services in cancer treatment.
However, this study had some limitations, including the restriction of articles to the English language.In fact, due to time and resource constraints, publications in other languages were not included.Moreover, this research solely focused on the interventional studies that analyzed the outcome of telemedicine technology and compared the results with the in-person visits.Therefore, other types of the research studies were excluded from the current study.Future studies can broaden their scope by incorporating various types of studies and objectives into their design to gain an indepth understanding of the use of telemedicine for different groups of patients and healthcare providers.
In contrast to systematic reviews, the scoping review did not formally evaluate the methodological quality or risk of bias of the included studies.This constraint directly results from the fundamental nature of scoping reviews, which primarily focus on mapping the existing evidence rather than critically evaluating individual studies.Nevertheless, future studies could incorporate quality assessment methods to enhance the credibility of the results by conducting systematic reviews.

Conclusion
This study aimed to investigate the use of telemedicine technology for cancer patients during the Covid-19 pandemic.The research findings provided a valuable insight into the use of various telemedicine technologies, services, and users' opinions about, and clinical outcomes of these services.The results showed that in most studies positive outcomes in terms of patients' and providers' satisfaction and clinical aspects were reported after using telemedicine interventions.This shows that overall, the context is ready to accept the technology and there are a number of opportunities for expanding the use of telemedicine technology, particularly for cancer patients.Therefore, future research should focus on identifying optimal strategies for implementing telemedicine for cancer care while taking into account both the clinical and non-clinical effectiveness of various services and technologies.

Fig. 1
Fig. 1 Process of selecting articles

Table 2
Summary of the selected studies